| Certificate Number | 573 | | Date Issued |
| Child Given Name | |
Gregory | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 30 Jun 1887 |
Franklin Twp Story Co IA | Place of Birth |
| Father's Given Name | S.D. |
Gregory | Father's Surname |
| Father's Birth Place | Illinois | 26 | Father's Age |
| Mother's Given Name | Nettie | Davis | Mother's Maiden Name |
| Mother's Surname | | Franklin Twp Story Co IA | Mother's Residence |
| Mother's Nationality | | Iowa | Mother's Birth Place |
| Mother's Age | 20 | 1 | Number of Child This Mother |
| Medical Attendant's Name | H.M. Templeton | a, | Medical Attendant's Address |